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The Utilization Management Nurse 1 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 1 work assignments are often straightforward and of moderate complexity.

Responsibilities

The Utilization Management Nurse 1 uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. Coordinates and communicates with providers, members, or other parties to facilitate optimal care and treatment. Understands own work area professional concepts/standards, regulations, strategies and operating standards. Makes decisions regarding own work approach/priorities, and follows direction. Work is managed and often guided by precedent and/or documented procedures/regulations/professional standards with some interpretation.

"LI-remote"

"This is a remote position"

Required Qualifications

• Active LPN or LVN license
• Compact license or licensed in multiple states without restrictions.
• Health Plan experience
• Ability to work independently under general instructions and with a team
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Prior clinical experience preferably in an acute care, home health, skilled or rehabilitation clinical setting.
• Previous experience in utilization management, discharge planning and/or home health or rehab
• Previous utilization review experience
• Previous Medicare/Medicaid Experience a plus
• Bilingual is a plus

Additional Information

Scheduled Weekly Hours

40